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General NPI Number Information
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NPI Number | 1326531534
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Entity Type | Organization
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Legal Business Name | SIDAROUS, LLC
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Dates
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Enumeration Date | 06/12/2018
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Last Update Date | 11/13/2024
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Provider Practice Location Address
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Address Line | 11521 W MARKHAM ST
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City | LITTLE ROCK
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State | AR
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Zip | 72211-2701
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Country | US
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Telephone | 501-502-2765
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Fax | 501-302-1991
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Provider Business Mailing Address
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Address Line | 11521 W MARKHAM ST
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City | LITTLE ROCK
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State | AR
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Zip | 72211-2701
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Country | US
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Telephone | 501-502-2765
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Fax | 501-302-1991
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Authorized Official
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Title or Position | OWNER
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Name | DR. PETER SIDAROUS
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Credential | MD
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Telephone | 717-319-9672
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | E100-91
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License Number State | AR
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